New horizons in advance care planning: narratives, identity and cultural humility.

Advance care planning (ACP) is considered important for patient-centred care in serious illness, yet evidence it benefits patients is inconsistent. This reflects a lack of clarity over how ACP interventions are supposed to achieve their intended goals and what these goals should be, leading to variation in implementation. This article seeks to address this knowledge gap by focusing on the role of narratives. Although ACP draws on patients' illness narratives (their personal stories of illness, including hopes and fears), the role of these narratives is often unacknowledged. We systematically reviewed the evidence on narratives and ACP and synthesised the findings with broader multidisciplinary literature. Attending to patient narratives can be a route to achieving many goals of ACP (including preserving patient autonomy, strengthening relationships and preparing for end-of-life) and can help patients to maintain their identity, which is important for well-being but is disrupted by illness and frailty. The values underpinning ACP are culturally-specific, however, with less relevance for some patients: better appreciation of this is a step towards cultural humility and more equitable care. The role of clinicians in contributing to patient life narratives through ACP is controversial. Some argue that clinicians should shape their patient's narrative, helping them to make meaning at the end-of-life, while others have problematised expectations that patients tell, and clinicians facilitate, 'good death' stories. Synthesising existing knowledge provides clinicians with insights on how to approach end-of-life conversations through framing discussions around patient narratives and lays the foundations for future research exploring narrative approaches to ACP.